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Radiographic Features of Rectosigmoid Endometriosis
RADIOGRAPHIC ENDOMETRIOSIS
FEATURES
OF RECTOSIGMOID
GORDON J. CULVER, M.D., RUBENS MARCONDES AND ROY SEIBEL, M.D., BUFFALO, N. Y. (From the University Deaconess Hospital)
of
Buffalo
School
of
Medicine,
Buffalo
General
PEREIRA, M.D.,
Hospital,
and
Buffalo
T
HE condition referred to as endometriosis is not uncommon in gynecologic practice. Through several routes, endometrium can invade or become implanted upon practically every pelvic organ and more rarely upon extrapelvic organs. Colcock and Lamphier,” in a review of 213 patients with endometriosis who underwent exploratory operations, found 18.3 per cent to have endometriosis of the rectum, rectosigmoid, sigmoid, or small intestine. Kratzer and Salvatis reported that there was some degree of bowel involvement in 34.22 per cent of the 225 cases in their review. Javert7 stated that benign endometrial cells are capable of dissemination and metastasis along the same pathways followed by endometrial adenocarcinoma. By direct extension or by lymphatic spread to adjacent serosal surfaces, the endometrial cells can become implanted upon the intestines. Because of their close proximity, the rectum and rectosigmoid colon are the most frequently involved segments (70 to 80 per cent of the reported cases). However, many casesof involvement of the small intestines and of the appendix have also been reported.(3’ 11) Although endometriosis does occur in both early and late life, approximately 75 per cent of casesoccur between 30 and 50 years of age. Involvement of the rectosigmoid may be present without obstruction. In approximately 50 per cent, however, there will be some clinical evidence of obstruction. There is a high incidence of sterility associated with endometriosis, the percentage in the literature varying from 40 to 60 per cent. Cf I4 patients with endometriosis of the intestines seen at the Leahy Clinic from 1940 to 1950, 8 were childless, 5 had 1 child, and 1 was single.3 Common symptoms of endometriosis of the rectosigmoid colon arc: I. Menorrhagia and metrorrhagia 2. Dyspareunia 3. Pain in the rectum caused by the passageof stool, usually only at menses, or at least intensified at that time. 4. Symptoms of low-grade obstruction such as nausea, crampy pains, and constipation, which are more apt to occur during the menstrual period. 5. Extension of the menstrual backache to the thighs and legs. 6. A history of acquired dysmenorrhea appearing in a multipara, or a change in the type of pain of the dysmenorrhea of the multipara. 7. Unexplained sterility. This has not been t,rue of the casesin this report as only 1 out of 6 married women was childless. 1176
8. Recurrent diarrhea frequently coincident with the menstrual period without rectal bleeding. From review of the literature and the standpoint of logic this should be true. It is of interest to note, however, that in 4 of our 7 Gasps Berlin and Finestor& have rcrectal bleeding was the presenting complaint. ported a case of rectosigmoid endometriosis with bloody diarrhea and norln;lI menses.
9. Fairly
good general health without weight loss.
Sigmoidoscopy shows only narrowing of t,he affected area. Ballon, Strcau, and Simon’ were able to make the diagnosis of obstructive ulcerating endometriosis of the rectum by proctoscopic biopsy. Obviously, if the lesion is beyond the reach of the sigmoidoscope, no abnormalties will be noted. The only way to make a preoperative diagnosis then is by radiographic examination of the colon. The x-ray findings of rectosigmoid endometriosis by barium trnema can be classified into two groups, constricting and nonconstricting lesions. Implants on portions of t,he bowel which are freely suspended by a mesentery are less like6 to become constricting lesions than are implants upon portions of the l~owcl which are partially est,raperitoneal and more firmly attached. Two factors influence partial obstruction and hence the x-ray findings : first the cndometrial tumor may compromise the lumen of the bowel; and, second, the associated inflammatory reaction may produce active spasm and later constricting and fising fibrosis. This late cicatricial contra&are in some casesis the pt’incipal basis of the x-ray findings. In cmstricting lesions the following radiographic changes are not,ed : 1. Annular narrowing of variable length, usually relatively short, with or without an associated filling defect caused by the endometrial tumor. Most frequently the narrowing tends to be eccentric, as can be noted in the illustrations. 2. The a.rea of involvement is sharply demarcated. 3. The lesions are usually fixed and tender when palpated under fluoroscopir, observation. 4. Uost important is the fact that the mucosal folds are intact through t,hc lesions. In nonconstricting
endometriosis the findings are different :
1. A submucosal tumor is demonstrated with normal mucosa overlying and silrrounding the lesion. 2. The extraluminal extent of the lesion may produce varying degrees of displacement of the bowel as can be noted in several of the casesreported in this paper. 3. A localized spastic and irritable segment of bowel is seen above and below the lesion. 4. Under Auoroscopic control the lesions arc locally tender. 5. The variation in size of the tumor depending on the phase of the menstrual cycle may be extremely helpful in establishing a diagnosis. This was well illustrated by a casepresented in a previous article.* The differential diagnosis would include, mainly, primary colon carcinoma, diverticulitis, and secondary involvement of the colon by pelvic tumors and inflammatory masses. Carcinoma of the colon arises from the mucosa and destroys its normal patt.crn. Therefore the presenee of a normal mucous membrane pattern is the one most important x-ray feature that differentiates endometriosis from carcinoma of the colon. There could be a remote possibility of malignant degeneration in an endometrial implant which would, of course, confuse this differential point. Sampson9 stated that “external endometriosis probably has the same potential
CULVER,
1178
PEREIRA,
AND
SEIBEL
Am. J. Obsr. & tiynec. Lkcember. 1958
for malignant change as normally located endometrium.” Scottlo reported 2 cases of ovarian adenocarcinoma which had histologic features that accorded with Sampson’s criteria for malignant degeneration of endometrial implants. No cases of malignant endometriosis of the colon have yet been reported, however. In diverticulitis, the diverticula are easily demonstrated and there is marked associated spasm extending well above and below the region of actual involvement. The lesion itself is usually long and the irregular, jagged, saw-toothed margins are quite characteristic of diverticulitis. Perforation, with formation of a pericolic mass, can complicate the picture and make the differential diagnosis more difficult. When primary pelvic tumors actually invade the wall of the colon, the x-ray findings can simulate those of rectosigmoid endometriosis. Of great importance in the differential is the finding of the soft tissue mass of the pelvic tumor on the plain film. The necessity of differential diagnosis of rectosigmoid endometriosis from the more rare primary large bowel tumors, such as lipoma, leiomyoma, fibroma, and mesenteric cysts, seldom arises and is mentioned only for completeness.
Fig. I.--Case sigmoid junction. narrowing referred
1. Full-sized The inserted to in the text.
fllm shows the location of the lesion just above the rectopressure spot film demonstrates the characteristic eccentric Note the normal mucosal pattern through the involved area.
Case Reports CASE L-This was a 40-year-old a history of crampy lower abdominal strual period for many years. The
except
The physical examination for occasional occult
married white woman, gravida ii, pain, diarrhea, and rectal bleeding menses were normal.
was essentially negative. blood in the stools.
All
laboratory
para ii, who during each tests
were
gave men-
negative
A barium enema disclosed an area of narrowing in the sigmoid colon, appearing to lie just above the peritoneal reflection. The defect was somewhat eccentric, the major involvement being at the inferior aspect of the sigmoid in this area. The mucosal pattern was not disturbed and there was no indication of ulceration. It was thought that the findings were highly suggestive of involvement of the sigmoid colon by endometriosis.
L$;$;zr7G/)
RADIOGRAPHIC
FEATURES
OF
RECTOSIGMOID
ENDOMETRIOSIS
1179
At operation, many chocolate cysts were found on the surfaces of the pelvic organs and in the omentum. Two lesions were noted involving the sigmoid colon. One was at the mid-sigmoid area, while the second was just above the peritoneal reflection and was thought to be the one which had been demonstrated by the barium enema. Resection was deemed unwise. Hiopsies of the sigmoid lesions were carried out and surgical castration was pcrformed. of
old
The pathologic and recent
report of hemorrhages.
the
sigmoid
biopsies
was typical
cndometriosis
with
evidence
CASE 2.-This was a 45-year-old single white woman, who gave a history of lower This abdominal pain and discomfort radiating to the back for the past 3 or 4 years. was intensified by bowel movements and by urination. There were no systemic complaints and the menstrual history was normal.
Physical examination disclosed slight suprapubie tenderness. Pelvic and rectal aminations showed tenderness and induration, in the form of nodulations, in the left de-sac, and there was a suggestion of an orange-sized mass in the right adnexa.
excul-
A barium enema disclosed narrowing of the low sigmoid for an area about 11/r, inches in length. This seemed to be the result of infiltration of the submucosal wall. The overlying mucosa was normal. There was the impression of an extraluminal mass observed from above. A radiographic diagnosis of sigmoid endometriosis was suggested.
Fig.
P.-Case
3.
Oblique spot Arrows
flhn of the sigmoid indicate the direction
At operation an orange-sized of the sigmoid and involving the small hemorrhagic cysts in the salpingectomy were performed. anastomosis was carried out. The pathologic report with localized hemosiderosis mucosa were intact.
lesion of
demonstrates its extrinsic pressure.
submucosal
character.
chocolate cyst was found firmly adherent to the mesentery sigmoid colon immediately adjacent. There were multiple right ovary. Hysterectomy, bilateral oophorectomy, and The sigmoid lesion was then resected and end-icr-end
of the involving
resected lesion of the colon was the serosa and muscular coats.
CASE I.-This was a 40-year-old married white years she had complained of abdominal bloating and of her menstrual period. There were lower abdominal ments. Otherwise the menses were normal.
typical The
endometriosis submucosa and
woman, gravida ii, para ii. For 2 constipation during the first 3 days cramps associated with bowel move-
CULVER,
1180
Fig. ITlUCOSE3,.
lumen
Fig.
3.-Case 3. Spot f11ms The element of associated on different fllms.
4.-Case
mainder
Pelvic of
4.
Narrowing
examination the physical
of
of the secondary
PEXEIRA,
the spasm
AND
sigmoid colon is evidenced
sigmoid to the
show by
the narrowed variations in
with accentuation submucosal tumor.
showed lemon-sized masses examination was negative.
Am. J. Obst. & Gynec. December, 1958
SEIBEL
arising
of
from
the
segment with caliber of the
normal sigmoid
mucosal
pattern,
each
fold
ovary.
The
re-
~l;~~r;6
RADIOGRAPHIC
FEATURES
OF
RECTOYIGMOID
ENDOMETRIOSlS
11x1
A barium enema disclosed moderate narrowing of the mitl-sigmoid colon which result of involvement of this segment by an extrinsic submucosal mass involving hOP iel wall. This was interpreted as a pelvic tumor mass with sigmoid involvement. end .ometriosis was suggested. the
Fig.
Fig
5.-Case below
5. Eccentric as indicated
by
fi.-Ck.5~:
3.
surgical
O~ene~l
narrowing
arrows.
of the The
specimen
the
sigmoid mucosa
with through
very the
showing tumor.
the
intramural,
obvious narrowing
pressure effect is normal.
subnlucosal
Laparotomy disclosed an endomctrial cyst arising from each ovary. firmly adherent to the sigmoid colon and required sharp dissection The re was, in addition, a similar mass at the ileocecal junction, which was Bol ;h ovaries \\ere removed but no bowel resection XJ-as carried out. The pathologic report was endometriotie cysts of both ovaries.
lefl : was
lwatkrl
That on for rclm not renn
f
CULVER,
1182
PEREIRA,
AND
i\rn. J. Obsr. 5. c;\ “CC, Uecernbe,- , 19 isc
SEIBEL
CASE 4.-This was a 57-year-old married white nulligravid woman whose plaint was intermittent rectal bleeding for 2 months. There was no associated bowel habits, nor was there any complaint of pain. The menopause had followed oophorectomy and salpingectomy at the age of 34. The
physical
examination
was
noncontributory.
A barium enema showed an area of narrowing of the sigmoid with the descending colon. The narrowing was distinctly submucosal appearing somewhat accentuated, as is frequently encountered in disease. The radiographic interpretation was tumor of the sigmoid location.
Fig.
i’.-Case
Exploratory upper portion. was completely trial
6.
Spot
nlnls of the characteristic
operation The sigmoid submucosal.
sigmoid eccentric
lesion in narrowing
both oblique is evident.
at about its. junction with the fold pattern submucosal infiltrative wall in a submucosal
projections.
disclosed a tumor involving the wall of the was opened and explored and it was noted The tumor was dissected free and the colotomy
The pathologic report of glands and a considerable
only comchange in bilateral
the removed amount of
tumor stroma.
was
typical
Again
the
sigmoid in its that the lesion was repaired.
endometriosis
with
endome-
CASE 5.-The patient was a 64-year-old married white woman, gravida i; para i. Her only complaint was increasing constipation for the 6 months prior to admission. Prior to that time her bowel habits were normal. There was no history of melena or diarrhea. She had gone through an apparently normal menopause about 20 years previously. lower
Physical quadrant. A
sigmoid findings without
examination revealed Pelvic and rectal
a walnut-sized, movable, examinations mere negative.
nontender
barium enema showed a concave defect along the colon which produced some narrowing of the lumen were interpreted as the result of an extrinsic mass intraluminal extension.
inferior but was involving
At operation, a lesion infiltrating cm. above the peritoneal reflection. It ovary, and was adherent to the latter.
mass
in
border of nonobstructive. the bowel
the
left
the
midThe mall but
the wall was noted in the sigmoid colon about 5 extended from the left broad ligament and the left The ovary was removed, The sigmoid colon was
E;;~e~y
RADIOGRAPHIC
opened and probed but the overlying colon was carried
FEATURES
OF
RECTOSIGMOID
with a finger, which revealed mucous membrane was intact. out.
The surgical specimen showed hypertrophic endometrial type. There was also some endometrial endometriosis of the sigmoid colon.
Fig. K-Case 7. Full fllm of the rectosigmoid Arrows indicate the mass at the inferior wall. The a pericolic inflammatory mass. Note the normal
that An
ENDOMETRIOSIS
the lesion anterior
musculature stroma
area and diverticula mucosal
impinged resection
with present.
11X:3
upon the lumecr of the sigmoid
numerous glands The diagnosis
inserted spot 5lm of the led to the misinterpretation
Pattern
OverlYing
the
of was
lesion. of
maw.
CASE 6.-This patient was a 42.year-old married white woman, gravida iv, para iv. The patient’s menses had been normal up to 5 years prior to admission. At that time she developed dysmenorrhea which increased in severity. Seven months prior to admission she developed severe abdominal cramps with each menstrual period with associated blooll? diarrhea. This would subside with the cessation of menses. The physical examination was negative except for pelvic and rectal examinations. These disclosed fulness in the right adnexal region and there was a firm mass palpable behind the lower uterine segment extending from left to right. Sigmoidoscopy showed at 10 cm. a protrusion on the anterior wall of the sigmoid, interpreted as the result of the extrinsic mass. There was no break in the mucous membrane. A barium enema revealed a filling defect in the low sigmoid colon producing considerable narrowing of the lumen. The defect was smooth in outline and did not appear to distort the mueosal pattern. This was interpreted as a tumor involving the sigmoid wall lying in submucosal location. The diagnosis of endometriosis was suggested.
Cl;I,TER,
I 184
Exploratory operation There was a mass involving This 3M cm. in diameter. oophorectomy, and salpingectomy The pathologic sections triosis. CASF: 7.-This patient was scen by last two menstrual associated with the There was no diarrhea Physical
PEREIlI.Z,
AND
SEIBEL
ovaries which rc~v~altd cystic the low sigmoid colon which was biopsied but not removed. were l)erfornnd. of tire sigmoid lesion revealed
contained chocolate material. measured 6 cm. in length and Total hysterectomy, hilateral the
typical
changes
of endome-
patient was 47 years old, married, white, gravida iii, para iii. The her physician because of bright red rectal bleeding accompanying her periods. Twelve years previously, she had had rectal bleeding not menses. This was ccrrected by hemorrhoidectomy without recurrence. or pain associated with her present rectal bleeding.
examination
and
sigmoidoscopy
were
nrgativc.
A barium enema showed a localized area of narrowing at the junction of the proximal and middle thirds of the sigmoid colon. There were several diverticula evident in this region. The cstent of the involvement of t,he lumen was 5 cm. and there was extrinsic pressure from below on this segment. The interpretation was probable pericolitis with an inflammatory mass secondary to local diverticulitis. was
At operation a resection no other pelvic abnormality. The
pathologic
of
a sigmoid
was cndometrisl
report
Summary
was
carried
implant
out
on the
for wall
a sigmoid of
the
tumor.
sigmoid
There colon.
and Conclusions
1. Seven casesof endometriosis of the rectosigmoid have been presented. 2. The radiographic findings have been described. 3. These findings are sufficiently characteristic that, when combined with the clinical data, a correct diagnosis should bc possible in most cases. 4. It is of interest to note that, in the present 7 cases,and in the 2 previously reported,” only one of the 8 married women gave an indication of sterility. 5. Contrary to the impression gained from a review of the literature, rectal bleeding was a presenting complaint in 4 of our 7 cases. to this
We wish series.
to
thank
Dr.
Kenneth
Seagraves
for
allowing
us
to add
his
case
References 1. 2. 3. 4. 5. 6. 7. 8.
9. 10. 11..
Ballon, H. C., Stream G. J., and Simon, M. A.: Canad. M. A. J. 74: 817, 1956. Berlin. P. F.. and Finestone. E. 0.: New York J. Med. 49: 2081. 1949. Colcock, B. P., and Lamphier, T. A.: Surgery 28: 997, 1950. ’ Culver, G. J., and Caldwell, M. V.: J. Canad. A. Radiologists 2: 6, 1951. Gale, C.: Australian Pu: New Zealand J. Surg. 1: 323, 1931. Glenn, P. M., and Thornton, J. J.: J. A. M. 9. 115: 520, 1940. Javert, C. T.: Cancer 2: 399, 1949. Kratzer, G. L., and Salvati, E. P.: Am. J. Surg. 90: 866, 1955. Sampson, J. A.: Ahl. J. OBST. & GYNEC. 10: 649, 1925. Scott, R. B.: Cancer 2: 283, 1953. Senapati, M. K. : Brit. J. Surg. 4: 330, 1953.
(No.
7)
FEATURES
OF RECTOSIGMOID
GORDON J. CULVER, M.D., RUBENS MARCONDES AND ROY SEIBEL, M.D., BUFFALO, N. Y. (From the University Deaconess Hospital)
of
Buffalo
School
of
Medicine,
Buffalo
General
PEREIRA, M.D.,
Hospital,
and
Buffalo
T
HE condition referred to as endometriosis is not uncommon in gynecologic practice. Through several routes, endometrium can invade or become implanted upon practically every pelvic organ and more rarely upon extrapelvic organs. Colcock and Lamphier,” in a review of 213 patients with endometriosis who underwent exploratory operations, found 18.3 per cent to have endometriosis of the rectum, rectosigmoid, sigmoid, or small intestine. Kratzer and Salvatis reported that there was some degree of bowel involvement in 34.22 per cent of the 225 cases in their review. Javert7 stated that benign endometrial cells are capable of dissemination and metastasis along the same pathways followed by endometrial adenocarcinoma. By direct extension or by lymphatic spread to adjacent serosal surfaces, the endometrial cells can become implanted upon the intestines. Because of their close proximity, the rectum and rectosigmoid colon are the most frequently involved segments (70 to 80 per cent of the reported cases). However, many casesof involvement of the small intestines and of the appendix have also been reported.(3’ 11) Although endometriosis does occur in both early and late life, approximately 75 per cent of casesoccur between 30 and 50 years of age. Involvement of the rectosigmoid may be present without obstruction. In approximately 50 per cent, however, there will be some clinical evidence of obstruction. There is a high incidence of sterility associated with endometriosis, the percentage in the literature varying from 40 to 60 per cent. Cf I4 patients with endometriosis of the intestines seen at the Leahy Clinic from 1940 to 1950, 8 were childless, 5 had 1 child, and 1 was single.3 Common symptoms of endometriosis of the rectosigmoid colon arc: I. Menorrhagia and metrorrhagia 2. Dyspareunia 3. Pain in the rectum caused by the passageof stool, usually only at menses, or at least intensified at that time. 4. Symptoms of low-grade obstruction such as nausea, crampy pains, and constipation, which are more apt to occur during the menstrual period. 5. Extension of the menstrual backache to the thighs and legs. 6. A history of acquired dysmenorrhea appearing in a multipara, or a change in the type of pain of the dysmenorrhea of the multipara. 7. Unexplained sterility. This has not been t,rue of the casesin this report as only 1 out of 6 married women was childless. 1176
8. Recurrent diarrhea frequently coincident with the menstrual period without rectal bleeding. From review of the literature and the standpoint of logic this should be true. It is of interest to note, however, that in 4 of our 7 Gasps Berlin and Finestor& have rcrectal bleeding was the presenting complaint. ported a case of rectosigmoid endometriosis with bloody diarrhea and norln;lI menses.
9. Fairly
good general health without weight loss.
Sigmoidoscopy shows only narrowing of t,he affected area. Ballon, Strcau, and Simon’ were able to make the diagnosis of obstructive ulcerating endometriosis of the rectum by proctoscopic biopsy. Obviously, if the lesion is beyond the reach of the sigmoidoscope, no abnormalties will be noted. The only way to make a preoperative diagnosis then is by radiographic examination of the colon. The x-ray findings of rectosigmoid endometriosis by barium trnema can be classified into two groups, constricting and nonconstricting lesions. Implants on portions of t,he bowel which are freely suspended by a mesentery are less like6 to become constricting lesions than are implants upon portions of the l~owcl which are partially est,raperitoneal and more firmly attached. Two factors influence partial obstruction and hence the x-ray findings : first the cndometrial tumor may compromise the lumen of the bowel; and, second, the associated inflammatory reaction may produce active spasm and later constricting and fising fibrosis. This late cicatricial contra&are in some casesis the pt’incipal basis of the x-ray findings. In cmstricting lesions the following radiographic changes are not,ed : 1. Annular narrowing of variable length, usually relatively short, with or without an associated filling defect caused by the endometrial tumor. Most frequently the narrowing tends to be eccentric, as can be noted in the illustrations. 2. The a.rea of involvement is sharply demarcated. 3. The lesions are usually fixed and tender when palpated under fluoroscopir, observation. 4. Uost important is the fact that the mucosal folds are intact through t,hc lesions. In nonconstricting
endometriosis the findings are different :
1. A submucosal tumor is demonstrated with normal mucosa overlying and silrrounding the lesion. 2. The extraluminal extent of the lesion may produce varying degrees of displacement of the bowel as can be noted in several of the casesreported in this paper. 3. A localized spastic and irritable segment of bowel is seen above and below the lesion. 4. Under Auoroscopic control the lesions arc locally tender. 5. The variation in size of the tumor depending on the phase of the menstrual cycle may be extremely helpful in establishing a diagnosis. This was well illustrated by a casepresented in a previous article.* The differential diagnosis would include, mainly, primary colon carcinoma, diverticulitis, and secondary involvement of the colon by pelvic tumors and inflammatory masses. Carcinoma of the colon arises from the mucosa and destroys its normal patt.crn. Therefore the presenee of a normal mucous membrane pattern is the one most important x-ray feature that differentiates endometriosis from carcinoma of the colon. There could be a remote possibility of malignant degeneration in an endometrial implant which would, of course, confuse this differential point. Sampson9 stated that “external endometriosis probably has the same potential
CULVER,
1178
PEREIRA,
AND
SEIBEL
Am. J. Obsr. & tiynec. Lkcember. 1958
for malignant change as normally located endometrium.” Scottlo reported 2 cases of ovarian adenocarcinoma which had histologic features that accorded with Sampson’s criteria for malignant degeneration of endometrial implants. No cases of malignant endometriosis of the colon have yet been reported, however. In diverticulitis, the diverticula are easily demonstrated and there is marked associated spasm extending well above and below the region of actual involvement. The lesion itself is usually long and the irregular, jagged, saw-toothed margins are quite characteristic of diverticulitis. Perforation, with formation of a pericolic mass, can complicate the picture and make the differential diagnosis more difficult. When primary pelvic tumors actually invade the wall of the colon, the x-ray findings can simulate those of rectosigmoid endometriosis. Of great importance in the differential is the finding of the soft tissue mass of the pelvic tumor on the plain film. The necessity of differential diagnosis of rectosigmoid endometriosis from the more rare primary large bowel tumors, such as lipoma, leiomyoma, fibroma, and mesenteric cysts, seldom arises and is mentioned only for completeness.
Fig. I.--Case sigmoid junction. narrowing referred
1. Full-sized The inserted to in the text.
fllm shows the location of the lesion just above the rectopressure spot film demonstrates the characteristic eccentric Note the normal mucosal pattern through the involved area.
Case Reports CASE L-This was a 40-year-old a history of crampy lower abdominal strual period for many years. The
except
The physical examination for occasional occult
married white woman, gravida ii, pain, diarrhea, and rectal bleeding menses were normal.
was essentially negative. blood in the stools.
All
laboratory
para ii, who during each tests
were
gave men-
negative
A barium enema disclosed an area of narrowing in the sigmoid colon, appearing to lie just above the peritoneal reflection. The defect was somewhat eccentric, the major involvement being at the inferior aspect of the sigmoid in this area. The mucosal pattern was not disturbed and there was no indication of ulceration. It was thought that the findings were highly suggestive of involvement of the sigmoid colon by endometriosis.
L$;$;zr7G/)
RADIOGRAPHIC
FEATURES
OF
RECTOSIGMOID
ENDOMETRIOSIS
1179
At operation, many chocolate cysts were found on the surfaces of the pelvic organs and in the omentum. Two lesions were noted involving the sigmoid colon. One was at the mid-sigmoid area, while the second was just above the peritoneal reflection and was thought to be the one which had been demonstrated by the barium enema. Resection was deemed unwise. Hiopsies of the sigmoid lesions were carried out and surgical castration was pcrformed. of
old
The pathologic and recent
report of hemorrhages.
the
sigmoid
biopsies
was typical
cndometriosis
with
evidence
CASE 2.-This was a 45-year-old single white woman, who gave a history of lower This abdominal pain and discomfort radiating to the back for the past 3 or 4 years. was intensified by bowel movements and by urination. There were no systemic complaints and the menstrual history was normal.
Physical examination disclosed slight suprapubie tenderness. Pelvic and rectal aminations showed tenderness and induration, in the form of nodulations, in the left de-sac, and there was a suggestion of an orange-sized mass in the right adnexa.
excul-
A barium enema disclosed narrowing of the low sigmoid for an area about 11/r, inches in length. This seemed to be the result of infiltration of the submucosal wall. The overlying mucosa was normal. There was the impression of an extraluminal mass observed from above. A radiographic diagnosis of sigmoid endometriosis was suggested.
Fig.
P.-Case
3.
Oblique spot Arrows
flhn of the sigmoid indicate the direction
At operation an orange-sized of the sigmoid and involving the small hemorrhagic cysts in the salpingectomy were performed. anastomosis was carried out. The pathologic report with localized hemosiderosis mucosa were intact.
lesion of
demonstrates its extrinsic pressure.
submucosal
character.
chocolate cyst was found firmly adherent to the mesentery sigmoid colon immediately adjacent. There were multiple right ovary. Hysterectomy, bilateral oophorectomy, and The sigmoid lesion was then resected and end-icr-end
of the involving
resected lesion of the colon was the serosa and muscular coats.
CASE I.-This was a 40-year-old married white years she had complained of abdominal bloating and of her menstrual period. There were lower abdominal ments. Otherwise the menses were normal.
typical The
endometriosis submucosa and
woman, gravida ii, para ii. For 2 constipation during the first 3 days cramps associated with bowel move-
CULVER,
1180
Fig. ITlUCOSE3,.
lumen
Fig.
3.-Case 3. Spot f11ms The element of associated on different fllms.
4.-Case
mainder
Pelvic of
4.
Narrowing
examination the physical
of
of the secondary
PEXEIRA,
the spasm
AND
sigmoid colon is evidenced
sigmoid to the
show by
the narrowed variations in
with accentuation submucosal tumor.
showed lemon-sized masses examination was negative.
Am. J. Obst. & Gynec. December, 1958
SEIBEL
arising
of
from
the
segment with caliber of the
normal sigmoid
mucosal
pattern,
each
fold
ovary.
The
re-
~l;~~r;6
RADIOGRAPHIC
FEATURES
OF
RECTOYIGMOID
ENDOMETRIOSlS
11x1
A barium enema disclosed moderate narrowing of the mitl-sigmoid colon which result of involvement of this segment by an extrinsic submucosal mass involving hOP iel wall. This was interpreted as a pelvic tumor mass with sigmoid involvement. end .ometriosis was suggested. the
Fig.
Fig
5.-Case below
5. Eccentric as indicated
by
fi.-Ck.5~:
3.
surgical
O~ene~l
narrowing
arrows.
of the The
specimen
the
sigmoid mucosa
with through
very the
showing tumor.
the
intramural,
obvious narrowing
pressure effect is normal.
subnlucosal
Laparotomy disclosed an endomctrial cyst arising from each ovary. firmly adherent to the sigmoid colon and required sharp dissection The re was, in addition, a similar mass at the ileocecal junction, which was Bol ;h ovaries \\ere removed but no bowel resection XJ-as carried out. The pathologic report was endometriotie cysts of both ovaries.
lefl : was
lwatkrl
That on for rclm not renn
f
CULVER,
1182
PEREIRA,
AND
i\rn. J. Obsr. 5. c;\ “CC, Uecernbe,- , 19 isc
SEIBEL
CASE 4.-This was a 57-year-old married white nulligravid woman whose plaint was intermittent rectal bleeding for 2 months. There was no associated bowel habits, nor was there any complaint of pain. The menopause had followed oophorectomy and salpingectomy at the age of 34. The
physical
examination
was
noncontributory.
A barium enema showed an area of narrowing of the sigmoid with the descending colon. The narrowing was distinctly submucosal appearing somewhat accentuated, as is frequently encountered in disease. The radiographic interpretation was tumor of the sigmoid location.
Fig.
i’.-Case
Exploratory upper portion. was completely trial
6.
Spot
nlnls of the characteristic
operation The sigmoid submucosal.
sigmoid eccentric
lesion in narrowing
both oblique is evident.
at about its. junction with the fold pattern submucosal infiltrative wall in a submucosal
projections.
disclosed a tumor involving the wall of the was opened and explored and it was noted The tumor was dissected free and the colotomy
The pathologic report of glands and a considerable
only comchange in bilateral
the removed amount of
tumor stroma.
was
typical
Again
the
sigmoid in its that the lesion was repaired.
endometriosis
with
endome-
CASE 5.-The patient was a 64-year-old married white woman, gravida i; para i. Her only complaint was increasing constipation for the 6 months prior to admission. Prior to that time her bowel habits were normal. There was no history of melena or diarrhea. She had gone through an apparently normal menopause about 20 years previously. lower
Physical quadrant. A
sigmoid findings without
examination revealed Pelvic and rectal
a walnut-sized, movable, examinations mere negative.
nontender
barium enema showed a concave defect along the colon which produced some narrowing of the lumen were interpreted as the result of an extrinsic mass intraluminal extension.
inferior but was involving
At operation, a lesion infiltrating cm. above the peritoneal reflection. It ovary, and was adherent to the latter.
mass
in
border of nonobstructive. the bowel
the
left
the
midThe mall but
the wall was noted in the sigmoid colon about 5 extended from the left broad ligament and the left The ovary was removed, The sigmoid colon was
E;;~e~y
RADIOGRAPHIC
opened and probed but the overlying colon was carried
FEATURES
OF
RECTOSIGMOID
with a finger, which revealed mucous membrane was intact. out.
The surgical specimen showed hypertrophic endometrial type. There was also some endometrial endometriosis of the sigmoid colon.
Fig. K-Case 7. Full fllm of the rectosigmoid Arrows indicate the mass at the inferior wall. The a pericolic inflammatory mass. Note the normal
that An
ENDOMETRIOSIS
the lesion anterior
musculature stroma
area and diverticula mucosal
impinged resection
with present.
11X:3
upon the lumecr of the sigmoid
numerous glands The diagnosis
inserted spot 5lm of the led to the misinterpretation
Pattern
OverlYing
the
of was
lesion. of
maw.
CASE 6.-This patient was a 42.year-old married white woman, gravida iv, para iv. The patient’s menses had been normal up to 5 years prior to admission. At that time she developed dysmenorrhea which increased in severity. Seven months prior to admission she developed severe abdominal cramps with each menstrual period with associated blooll? diarrhea. This would subside with the cessation of menses. The physical examination was negative except for pelvic and rectal examinations. These disclosed fulness in the right adnexal region and there was a firm mass palpable behind the lower uterine segment extending from left to right. Sigmoidoscopy showed at 10 cm. a protrusion on the anterior wall of the sigmoid, interpreted as the result of the extrinsic mass. There was no break in the mucous membrane. A barium enema revealed a filling defect in the low sigmoid colon producing considerable narrowing of the lumen. The defect was smooth in outline and did not appear to distort the mueosal pattern. This was interpreted as a tumor involving the sigmoid wall lying in submucosal location. The diagnosis of endometriosis was suggested.
Cl;I,TER,
I 184
Exploratory operation There was a mass involving This 3M cm. in diameter. oophorectomy, and salpingectomy The pathologic sections triosis. CASF: 7.-This patient was scen by last two menstrual associated with the There was no diarrhea Physical
PEREIlI.Z,
AND
SEIBEL
ovaries which rc~v~altd cystic the low sigmoid colon which was biopsied but not removed. were l)erfornnd. of tire sigmoid lesion revealed
contained chocolate material. measured 6 cm. in length and Total hysterectomy, hilateral the
typical
changes
of endome-
patient was 47 years old, married, white, gravida iii, para iii. The her physician because of bright red rectal bleeding accompanying her periods. Twelve years previously, she had had rectal bleeding not menses. This was ccrrected by hemorrhoidectomy without recurrence. or pain associated with her present rectal bleeding.
examination
and
sigmoidoscopy
were
nrgativc.
A barium enema showed a localized area of narrowing at the junction of the proximal and middle thirds of the sigmoid colon. There were several diverticula evident in this region. The cstent of the involvement of t,he lumen was 5 cm. and there was extrinsic pressure from below on this segment. The interpretation was probable pericolitis with an inflammatory mass secondary to local diverticulitis. was
At operation a resection no other pelvic abnormality. The
pathologic
of
a sigmoid
was cndometrisl
report
Summary
was
carried
implant
out
on the
for wall
a sigmoid of
the
tumor.
sigmoid
There colon.
and Conclusions
1. Seven casesof endometriosis of the rectosigmoid have been presented. 2. The radiographic findings have been described. 3. These findings are sufficiently characteristic that, when combined with the clinical data, a correct diagnosis should bc possible in most cases. 4. It is of interest to note that, in the present 7 cases,and in the 2 previously reported,” only one of the 8 married women gave an indication of sterility. 5. Contrary to the impression gained from a review of the literature, rectal bleeding was a presenting complaint in 4 of our 7 cases. to this
We wish series.
to
thank
Dr.
Kenneth
Seagraves
for
allowing
us
to add
his
case
References 1. 2. 3. 4. 5. 6. 7. 8.
9. 10. 11..
Ballon, H. C., Stream G. J., and Simon, M. A.: Canad. M. A. J. 74: 817, 1956. Berlin. P. F.. and Finestone. E. 0.: New York J. Med. 49: 2081. 1949. Colcock, B. P., and Lamphier, T. A.: Surgery 28: 997, 1950. ’ Culver, G. J., and Caldwell, M. V.: J. Canad. A. Radiologists 2: 6, 1951. Gale, C.: Australian Pu: New Zealand J. Surg. 1: 323, 1931. Glenn, P. M., and Thornton, J. J.: J. A. M. 9. 115: 520, 1940. Javert, C. T.: Cancer 2: 399, 1949. Kratzer, G. L., and Salvati, E. P.: Am. J. Surg. 90: 866, 1955. Sampson, J. A.: Ahl. J. OBST. & GYNEC. 10: 649, 1925. Scott, R. B.: Cancer 2: 283, 1953. Senapati, M. K. : Brit. J. Surg. 4: 330, 1953.
(No.
7)